1 1 Ischemic Heart Disease (IHD – coronary Heart Disease) Introduction to Primary Care: a course...
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Transcript of 1 1 Ischemic Heart Disease (IHD – coronary Heart Disease) Introduction to Primary Care: a course...
1 1
Ischemic Heart Disease(IHD – coronary Heart Disease)
Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
objectives:
At the end of this session the trainee will be able to • be able to discuss the burden of IHD.• describe essential elements in history taking & examination• develop a differential diagnosis of chest pain.• describe appropriate diagnostic testing for chest pain.• discuss modifiable & non modifiable risk factors for cardiac disease.• describe the use of investigation in the evaluation of a patient with
chest pain.• appropriatly use of specialty referral.
Prevalence of IHD
• Heart diseases responsible for overal deaths in the
Saudi population:
– IHD : 17%
– Hypertensive heart disease 9%
– CVA : 4%
18th scientific session of the Saudi Heart Association. 2007 http://www.highbeam.com/doc/1G1-158905180.html
History taking in CAD
• Patient characteristics (Name, age, sex,occupation)
• Pain (duration, location, intensity,nature,aggravating factors
• Associated symptoms (Dyspnea, syncope….etc)
• Past history (HPN,DM,COPD..ETC)
• Family history (coronary artery disease ,pneumothorax)
• Drug history (antiangina,anti diabetic..etc)
• Life style (Diet, exercise, alcohol, smoking )
• Psychosocial (ICE, anxiety, stress )
What characteristics of the chest pain might make you more concerned for cardiac chest pain?
• Location• Associated
Symptoms• Quality• Chronology• Onset
• Duration• Intensity• Exacerbating• Relieving• Situation
Physical Examination
• General Examination – patient status: stable,notstable,inpain or not in pain.
– Vital signs.
– Obese or overweight.
– Skin appearance.
• Cardiovascular &respiratory system examination– BP, Pulse rate, JVP.
– Chest :apex beat deviation, crepitations, decrease breath sounds.
– Heart : 1st & 2nd heart sounds, gallop, friction rub.
– Abdomen: tenderness, guadring….
Any exam findings that might help distinguish cardiac from non cardiac chest pain?
• General Appearance – may suggest seriousness of
symptoms.
• Vital signs – marked difference in blood
pressure between arms suggests aortic dissection
• Palpate the chest wall – Hyperesthesia may be due
to herpes zoster
• Complete cardiac examination– pericardial rub– Ischemia may result in MI
murmur, S4 or S3
• Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation
What would be the differential diagnosis for
chest pain?
Life threatening Causes Non-life threatening CausesCardiovascular(16%):• Myocardial infarct.• Angina.•Thoracic aortic dissection.
Pulmonary (5%):•Pulmonary embolus.•Pulmonary infarction.•Tension pneumothorax.•Pneumonia.•Pleurisy.
Chest wall (33%):•Trauma•Fracture•Costo-chondritis.•Musculoskeletal.
•Gastrointistinal(20%):•Esophageal spasm•Esophagitis.•Gall bladder disease.•Peptic ulcer disease.•pancreatitis
Psychatric (9%):• Anxiety.
Spinal dysfunction:• Cervical disease.
Infections (rare):• Herpes Zoster.
..
The risk factors for CAD
• Age > 45 (male) and >55 (female).• Smoking.• Family history.• Hyperlipidemia. • Diabetes. • Hypertension.• Obesity.• Sedentary life style.• Anxiety.• Drug addiction.• Past History.
Any tests that might help in diagnosis?
•History and Examination
•ECG
•Cardiac Enzymes
•Chest x-ray.
•Upper GI endoscopy.
Cont…
• ECGST elevation of > 1mm or new Q in 2 leads
– Sensitivity 45%
Above + ST depression or T-wave inversion – Sensitivity 79%– False positive rate = 17%
20% of patients having an MI will have a normal ECG initally
Cont…Cardiac enzymes:• Troponin, CK, myoglobin
– 88-90% sensitive at 4-6 hours– 95-100% sensitive 8-12 hours
Source: Am Heart J 1998 Aug;136(2):237-44
Risk CategoryRisk CategoryLDL GoalLDL Goal(mg/dL)(mg/dL)
LDL Level at LDL Level at Which to Initiate Which to Initiate
Therapeutic Therapeutic Lifestyle Changes Lifestyle Changes
(TLC) (mg/dL)(TLC) (mg/dL)
LDL Level at Which LDL Level at Which to Considerto Consider
Drug Therapy Drug Therapy (mg/dL)(mg/dL)
CHD or CHD Risk CHD or CHD Risk EquivalentsEquivalents
(10-year risk >20%)(10-year risk >20%)
Very high riskVery high risk
<<100100
< < 7070) ) VHRPVHRP((
100100 130 130 (100(100––129: drug 129: drug
optional)optional)
<) <) 100100 : :drug optionaldrug optional((
22 + +Risk Factors Risk Factors (10-year risk (10-year risk 20%)20%)
))moderately high moderately high risk ptrisk pt( (
1010--year risk < 10%year risk < 10%
<<130130
<<100100))theraputic theraputic optionoption((
<<130130
100100
130130
1010--year risk 10year risk 10––20%: 20%: 130130
100-129100-129
1010--year risk <10%: year risk <10%: 160160
00––11 Risk FactorRisk Factor <<160160 160160
190 190 (160(160––189: LDL-189: LDL-lowering drug lowering drug
optional)optional)
• Diabetes is regarded as a CHD Risk Equivalent
• 10-year risk for CHD 20%
• High mortality with established CHD
– High mortality with acute MI
– High mortality post acute MI
Initial Approach• ABC assessment
• 100% Oxygen
• Aspirine
• Nitroglycerine
• IV access
• Morphine
• Monitoring
• ECG quickly
Action Plan
Action Plan
Source: http://www.aafp.org/afp/20050701/119.html
Referral
Refer urgently all the serious conditions with chest pain:
• Cardiac causes.• Esophageal spasm.• Pulmonary embolism.• Any other cases not responding to usual treatment.
Important Points• The likelihood of acute coronary syndrome (low, intermediate,
high) should be determined in all patients who present with chest pain.
• A 12-lead ECG should be obtained within 10 minutes of presentation in patients with ongoing chest pain.
• Cardiac markers (troponin T, troponin I, and/or creatine kinase-MB isoenzyme of creatine kinase) should be measured in any patient who has chest pain consistent with acute coronary syndrome.
http://www.aafp.org/afp/20050701/119.html
Important Points
• A normal electrocardiogram does not rule out acute coronary syndrome.
• When used by trained physicians, the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (a computerized, decision-making program built into the electrocardiogram machine) results in a significant reduction in hospital admissions of patients who do not have acute coronary syndrome.
http://www.aafp.org/afp/20050701/119.html